(The patient) is chained to actions that neither

his reason nor emotions have originated ,

that his conscience rejects and
his will cannot suppress.
Esquirol, Des Maladies Mentales Considerees
Sur les Rapports Medical , Hygienique et Medico- Legal, 1838
Obsessive Compulsive Disorder
Etiology & Pathophysiology

Presenter: Dr Kushal D. Jain

Chairperson: Dr Mamta Sood

24-01-07
 Outline of Presentation
• Introduction
• Etiology
• Pathophysiology
• OCD & Tic disorder
• Schizo-Obsessive subtype
• Conclusions
• Future directions
 Features of OCD
• Obsessions
– Recurrent and persistent thoughts, impulses or images
– Intrusive and distressing
– Ego dystonic, irrational
– Individual tries to ignore, suppress, or neutralize
• Compulsions
– Repetitive behaviors individual feels driven to perform
– Ritualistic/need to follow a set of rules
– Intended to prevent or reduce distress or some dreaded
event
 Epidemiology of OCD
• W.H.O(1994): OCD is one of the world’s top ten causes of
illness related disability

• 4th most common disorder after phobias, substance abuse, and

depression

• Lifetime prevalence of 2-3%

• More occurrence in men, Sex ratio is 1:1.1 (men to women)

• Mean age of onset is 20.9 years (SD=9.6)

– Males is 19.5 years (SD = 9.2)
– Females is 22.0 years (SD = 9.8)
(Epidemiological Catchment Area Study )
 Classification ICD 10
• F.42 OCD
• Predominantly Obsessive Thoughts Or
Ruminations
• Predominantly compulsive acts
• Mixed obsessional thoughts and acts
• Other obsessive compulsive disorder
• Unspecified
• Types of Obsessions • Types of compulsions
– Aggressive – Cleaning/washing
– Contamination – Checking
– Sexual obsessions – Repeating rituals
– Hoarding/saving – Counting
– Religious
– Ordering/arranging
– Symmetry/exactness
– Hoarding/collecting
– Somatic
– Mental rituals
 Forms of obsessions
Obsessional thoughts, words, phrases
Obsessional images,
Obsessional ruminations- worrying themes, train of
thoughts, less intrusive.
Obsessional doubts
Obsessional impulses
Obsessional fear of illness
Obsessional slowness
 Diagnostic Criteria
• Presence of obsessions or compulsions
• Ego Dystonic, realize thoughts and actions
are irrational or excessive
• Unable to control the thoughts
• Must take up more than 1 hour a day
• Must disrupt daily functioning
 • Psychodynamic

What causes OCD? • Behavioral

• Cognitive
‘The Etiology’
• Biological
 Psychodynamic factors
Freud
• Rat man (Ernst Lanzer, 1878-1914)
• ‘Obsessional neurosis’
• Fixation at anal stage (instillation of shame and
guilt)
• Defenses: reaction formation, doing and undoing and
isolation of affect
• Psychodynamic meaning of psychodynamic stressors,
pregnancy or childbirth, (onset or exacerbation of symptoms)
• Treatment resistance: poor compliance
• Interpersonal meanings
 Behavioral factors
• Neutral stimuli because associated with aversive stimuli
through a process of classical conditioning and come to elicit
anxiety

• Compulsions are learned, reinforced because they reduce fear

• Support for anxiety reduction in OCD

– Behavior therapy : Exposure & Response prevention technique for
OCD
(Mineka & Zinbarg, 1996)
 Cognitive factors
• Obsessions have their origin in normal intrusive cognitions, that
occur in at least 90 % of the general population
(Rachman & De Silva, 1978)

• Common types of interpretations/beliefs that influence the

development of OCD
– Responsibility for harm
– Overestimation of threat
– Perfectionism
– Intolerance of uncertainty
– Over-importance of thoughts
– Need to control thoughts
– Thought action fusion
(Carson and Butcher: In Textbook of Abnormal
Psychology)
 External Cue
passes church
Biology
genetics,
physiology
Intrusions
“Damn God”

Mood
frustrated

Interpretations
Family/ God will punish me
Life experiences
strict Cath.
childhood
Emotions
anxious, depressed

Core beliefs
“I’m
bad”
Behavior
says a prayer,
avoids driving
 Unwanted
Thoughts

Relief from anxiety Anxiety

Compulsive behavior
 Biological factors
• Serotonin- Dysregulation of serotonin
• Abnormality of the serotonergic system
• Lowers in amount of norepinephrine
 Genes
• High concordance rate among monozygotic twins
• First degree relatives 5-7%
Brain Imaging studies
• Pet scan- increased activity in frontal lobe, basal
ganglia and cingulum
• EEG abnormality marked over temporal lobes
 Co morbidities
• Depression
• Social phobia
• Panic disorder
• Eating disorder
• Anxiety disorder
• Personality disorder- Anxious avoidant, ocpd
• PTSD
• Psychosis
• Tourette’s Synrome
 Treatment
• Medicatons
• Behavioral therapy
• Cognitive and behavior therapy
• rTMS
Behavioral therapy
•ERP
•Desensitization
•Flooding
Cognitive therapy- Drill therapy
•Thought stopping
•Psychoeducation
•Cognitive Restructuring
Cognitive Hynotherapy
rTMS
 Anterior cingulate
• Anterior cingulate abnormality : Overactive action-monitoring
system (Ursu 2003, Van
2002)

• Cingulotomies : severe, treatment-refractory OCD

(Rauch et al 2000)

• Findings also suggest posterior cingulate dysfunction

(Rauch et al 2001)

• Contextual fear conditioning and reward expectancy both of

which are highly relevant to behavioral theories in OCD
(Frankland 2004)
 Recent studies…
Reduced Orbitofrontal-Striatal Activity on a Reversal
Learning Task in Obsessive-Compulsive Disorder
(Remijnse 2006)
• Compared to healthy controls patients with OCD:
– Impaired task end result

– Adequate behavior on receipt of punishment and with regard to affective

switching.

– On reward outcome, decreased responsiveness in right medial and lateral

OFC as well as in the right caudate nucleus

– During affective switching, patients recruited the left posterior OFC,

bilateral insular cortex, bilateral dorsolateral, and bilateral anterior
prefrontal cortex to a lesser extent
 Recent studies…
Frontal-Striatal Dysfunction During Planning in Obsessive-
Compulsive Disorder (Van den Heuvel et al 2005)
• Compared with control subjects OCD patients:

– Significant planning impairments

– During planning, decreased frontal-striatal responsiveness (dorsolateral

PFC and caudate nucleus).

– Compensatory involvement of brain areas known to play a role in

performance monitoring and short-term memory processing (anterior
cingulate, ventrolateral prefrontal, and parahippocampal cortices)

• Described frontal-striatal dysfunction in OCD is independent of state

anxiety and disease symptom severity